What is a Rotator Cuff Tear?
The rotator cuff of the shoulder is a group of 4 muscles (the suprasprinatus, subscapularis, infraspinatus and teres minor) that surround the uppermost part of your arm (the humerus bone). Together the rotator cuff muscles form a suction force that pulls the humerus into the shoulder blade and keeps the joint stable during arm movements.
Sometimes, the rotator cuff can be injured – strained, inflamed and torn when loads are given to the shoulder that it is unable to handle. These activities may include heavy weight lifting, repetitive arm movements, or a sudden jolt to the shoulder like a fall or a car accident.
Injuries to the rotator cuff are quite common but they are more common in older adults because of their shoulders being weaker and more deconditioned, so simple activities like falling or being pulled on the dog's leash can sometimes cause a tear. If rotator cuff tears are left untreated, they could cause severe pain and disability, rendering the arm and shoulder unable to be used.
Severity of rotator cuff tears can be classified as full-thickness or partial-thickness, judging on how extensive the tear is through the muscle. Full-thickness tears is exactly how it sounds: a tear extending from the top to the bottom of the muscle or tendon. Partial-thickness tears involve a disruption of the muscle or tendon through some portion, but the damage does not extend all the way through the structure.
As mentioned earlier, rotator cuff tears can either develop through traumatic and sudden injury from an event or may develop over time with repetitive overhead use. These can then be classified as acute and as chronic rotator cuff tears respectively.
Patients with chronic rotator cuff injuries often have histories of shoulder impingement syndrome, with involves a chronic and repetitive irritation of the rotator cuff tendon through repetitive use and poor postural and scapular mechanics.
Because of the complex mechanism of acute injuries, and also because of chronic compensations of other muscles and structures, rotator cuff tears can also occur in conjunction to other shoulder injuries such as biceps tendonitis and labral tears (the labral being a ring of cartilage surrounding the inside of the shoulder blade that faces the humerus).
Symptoms of a Rotator Cuff Tear
Following are what patients typically feel with a rotator cuff tear:
- Pain on top of the shoulder or a radiation of pain down the side of the upper arm
- Shoulder weakness
- Loss of shoulder range of motion
Patients often describe the injured arm as feeling weak, heavy and painful while lifting. In severe full-thickness tears, the pain may completely stop patient from performing their daily activities because of the inability to raise the arm. Other telltale signs of a rotator cuff tear disorder is the inability to reach high shelves or overhead, reach behind their backs, tuck in their shirts, or fasten their bra.
How Is A Rotator Cuff Tear Diagnosed?
Contrary to what most patients think, a physical therapist is well equipped in their training and knowledge to hone in on a rotator cuff tear diagnosis. Your PT will gather a subjective report from you about your health history, your pain levels, functional limitations and what we in Stride Strong PT like to call your 'asterisk sign' – a repeatable and symptomatic motion that elicits the shoulder pain.
Your physical therapist then will conduct a series of tests to measure the strength and range of motion deficits on your shoulder injured shoulder. Additionally, he/ she will perform some specialized tests that could further narrow in on the injured tendon in question and, with a degree of accuracy, tell whether there is a rotator cuff tear involvement. Some of these tests include Neer's impingement sign, Hawkins-Kennedy test, the belly press test, and the external rotation lag sign. A lot of these tests aim to elicit the exact same pain that patients are feeling to delineate which tendons are involved; and they usually involve the patient moving through a certain range, sometimes against resistance, at a specific angle of elevation. The eliciting of pain does not cause extra damage that wasn't already there but biases the exact tendon of the rotator cuff so the therapist is able to ascertain which movements the patient should avoid.
In some cases, such as in the suspicion of a full thickness tear, your physical therapist may need to refer out to an orthopedic surgeon for further diagnostics and treatment. An MRI, or madnetic resonance imaging, exam would be able to further show the severity of the shoulder injury and the need for surgical intervention.
Physical Therapy for a Partial-Thickness or Chronic Rotator Cuff tear?
When a partial-thickness rotator cuff tear is diagnosed and surgery is not recommended initially for the treatment of your tear, your physical therapist will get to work on a plan of care to restore range of motion, strength, scapular stability and posture so you can return to daily activities and sports activities with less symptoms. Oftentimes, activity modification is needed in the beginning, so the offending structure is not strained even more. There is also a significant amount of muscle guarding and neck tension that happens in conjunction with a rotator cuff tear, and although intuitive at first, could cause significant secondary discomfort. Your physical therapist will be able to give you the postural changes and exercises needed to prevent this.
If the surgical route is chosen by your healthcare team, your physical therapist can also help to jump-start healing and strengthening even pre-operatively to make sure those guarding and compensatory mechanisms are not present when you start rehab after surgery.
It is always the most prudent to seek out a physical therapist or a physician after the onset of a traumatic shoulder injury. Not only can fast intervention allow for fast healing, but also other life-threatening disorders can be ruled out by your healthcare professional.
Physical Therapy for Post-surgical Repair of the Rotator Cuff
A full-thickness tear of the rotator cuff usually warrants surgical intervention to repair the tear. Physical therapy is a vital part of healing after the surgery. The newly stitched and repaired rotator cuff is vulnerable to re-tear after shoulder surgery and physical therapists are equipped with the knowledge on how to safely progress movement and use of the injured shoulder. Close communication with the physician is made so as to follow the surgeon's protocol for after-surgery care.
During the initial stages after a rotator cuff repair, a patient is usually supported in a sling. The early stages of physical therapy involve gaining range of motion and decreasing post-surgical pain within a safe range, always respecting the healing of the rotator cuff. As the patient's range of motion progresses, light strengthening exercises are prescribed to you by your PT to strengthen the scapular muscles and the rotator cuff in a very gradual manner. During this stage, however, the patient may still have a lot of trouble accomplishing daily tasks like bathing, dressing and cooking. Sleeping may be difficult, and your physical therapist can arm you with some tools and suggestions to minimize pain and maximize function, while letting the tear heal. Your physical therapist may use gentle massage to calm down hypertonic muscles and may use a combination of cold therapy and electric stimulation for pain relief. Although these visits may not be completely comfortable and pain-free, not going through with the physical therapy protocol in an adequate amount of time may result in debilitating frozen shoulder syndrome.
Once the patient is out of the sling and tolerating more activity, prescribed exercises will become a little more difficult qw your physical therapist progresses you. Scapular stability is more of a pressing issue so proper shoulder mechanics can start to restore. The patient may be able to do some active moving of the arm, but heavy lifting of weights must be avoided as the tear is still healing. Hands-on mobilization of the arm and shoulder is still needed at this stage to keep working on healthy range of motion.
The last phase of shoulder rehab focuses on return to work and sports. Because the demands for different people vary, the amount and intensity of exercise will also vary. It is important at this stage for the patient to communicate the several common tasks that the patient routinely undergoes so that the same motions and loads are practiced in the clinic under guidance of the physical therapist. Pt visits may be less frequent at this stage as patients are given a more intense home or gym program for strengthening. For return to sports, a series of challenging maneuvers can be continually tested to make sure the athlete is ready to take on the loads of his/her sport.
What If I don't have a tear, but just shoulder impingement. Is there anything I can do?
A rotator cuff physical therapist can help decrease minimize the progression of a shoulder impingement into a rotator cuff tear. Research studies also bolster the efficacy of PT having "...significant improvement in pain scores, functionality, and patients' quality of life". (Resource: https://www.ncbi.nlm.nih.gov/pubmed/31341826) Here is what can be done at your physical therapy appointment:
- Rotator cuff and periscapular strengthening is very important in preventing further damage on the offending tendon.
- Avoidance of certain overhead motions in certain angles can help decrease the stress on the tendon.
- Posture re-education. A rounded shoulder posture can further exacerbate shoulder impingement and sets the patient up for a future tear. It is vital to restore proper posture during daily habits, especially during overhead motions.
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